Semcac Family Planning Clinic

PATIENT REGISTRATION

Date of Birth: ____/____/______Biological Sex- Female: ____ Male: ____ Decline to answer: ____
Identify As- Female: ____ Male: ____ Transgender (FTM): ____ (MTF): ____ Genderqueer: ____ Other: ______
What pronouns do you prefer? ______

Last Name: ______First Name: ______Middle Initial: ______

Preferred Name: ______Phone Number: (_____) ______

Address:______Can we leave a message: Yes ____ No: ____
City: ______When calling, how should we identify ourselves?
State: ______Zip:______Semcac Clinic ____

Social Security Number: _____-_____-______Other: ______
Email Address: ______

May we send mail to this address? Alternative Address: Semcac must be able to

(all mail is sent with anonymous return) contact you by mail.

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Semcac Family Planning Clinic

Yes No, If No you are requesting not to receive mail for confidential reasons and must provide us with an alternative address where we may contact you.

Name: ______

Address: ______

City: ______

State: ______Zip: ______

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Semcac Family Planning Clinic

Emergency Contact: Name: ______Relationship:______

Phone: ______

The following information is used for statistical purposes:

  1. Marital Status: Single Married Separated

Divorced Widowed Domestic Partner

  1. What race do you identify yourself as? Mark one or more

White Native American/Alaskan Native Asian

Black/African American Native Hawaiian/Pacific Islander Other

  1. Are you of Hispanic/Latino origin or descent? Yes No
  2. If you are less than age 18 are your parent(s)/guardian aware of your visit today?

Yes No

Additional Demographics:
Student Status: ____Yes ____ NoDisabled: ____ Yes ____No
Education Level: ____ 0-8 GradeHousing Type: ____ Own
____ 9-12 Grade Non-Graduate ____ Rent
____ High School Grad/GED ____ Homeless
____ 12+Some Post-Secondary ____ Other
____2/4 Yr College Grad or Beyond
Family Type: ____Single Person
____ Single Parent/Female
Number of Children Now Living (born to you): ______Single Parent/Male
____ 2 Parent Household
____ 2 Adults/No Child
INSURANCE INFORMATION

My insurance is: Public Health Insurance Private Health Insurance No Insurance Unknown

 I want to use my insurance. Please present all insurance cards to the receptionist.
Policy Holder’s Name: ______Policy Holder’s Date of Birth: ______
 I do not have any insurance.

I do not want to use my insurance for confidentiality reasons and agree to be responsible for any applicable charges.______

FINANCIAL INFORMATION: If you would like to see if you qualify for a discount, please fill out the following.

Fees are based on income and family size. You are responsible for the charges for the services you receive.

 I prefer to not declare my income, and I agree to pay the full price for the services I receive.
SOURCES OF INCOME: This includes all of yours and your spouse’s/partner’s pre-taxed wages (including tips); allowance/parental support; public assistance (MFIP, SSI); unemployment compensation; child support; alimony; or veteran’s/military allotments.
(Circle One)
Your weekly income is: $______weekly / biweekly / monthly / annually

Spouse/ Partner’s Income: $______weekly / biweekly / monthly / annually

**If you are less than age 18 and your parent(s)/guardian are aware of your visit, their weekly income is:

Weekly income is: $______

______

HOUSEHOLD/FAMILY SIZE: How many people, including yourself, does this income support? ______

______

PATIENT AGREEMENT

To the best of my knowledge all personal and health related information provided to

Semcac Clinic is complete and correct.

By signing this form and when using insurance, you are stating you AGREE with the following statements:
  • I understand I am responsible for charges for all services, including those not covered by my insurance or grant.
  • I authorize the release of any medical or other information necessary to process a claim.
  • I authorize the release of any medical records necessary for continuing care to another health care entity/provider.
  • I authorize payment of medical benefits to Semcac
  • I understand that services provided to me may appear on a statement of benefits sent to the policy holder (i.e. parents/spouse)

Patient Signature: ______Date: ______

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